216803917-7-31-2025-21-AS-BMOS-DKHSRA-20250813140601

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 216803917
Report Date: 07/31/2025
Date Signed: 07/31/2025 10:24:05 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/05/2025 and conducted by Evaluator Anthony Loera

COMPLAINT CONTROL NUMBER: 21-AS-20250605090523

FACILITY NAME:	SHALAMO HOME		FACILITY NUMBER:	216803917
ADMINISTRATOR:	GONGORA,JASMIN		FACILITY TYPE:	737
ADDRESS:	200 DARYL AVENUE		TELEPHONE:	(415) 493-6622
CITY:	NOVATO	STATE: CA	ZIP CODE:	94947
CAPACITY:	4	CENSUS: 3	DATE:	07/31/2025
		UNANNOUNCED	TIME BEGAN:	09:25 AM
MET WITH:	Lead Staff, Kasandra Renteria		TIME COMPLETED:	10:35 AM

ALLEGATION(S):

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Staff are feeding residents food that is not of good quality
Facility did not have a direct care lead staff on duty at all times
Staff did not provide adequate supervision resulting in resident missing their medication dosage
Staff are not properly trained to dispense medication

INVESTIGATION FINDINGS:

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On 07/31/2025, Licensing Program Analyst (LPA) Loera conducted an unannounced visit for the purpose of delivering complaint findings regarding the above allegations. LPA arrived and met with Lead Staff, Kasandra Renteria. During the investigation, LPA conducted interviews, reviewed documents and made observations.

Complainant alleges, Staff are feeding clients food that is not of good quality, Staff did not provide adequate supervision resulting in client missing their medication dosage, Facility did not have a direct care lead staff on duty at all times and staff are not properly trained to dispense medication.

Based upon department document review and interviews, information provided was contradicting with a lack of corroborating evidence to support the allegation(s). Complaint alleged staff are feeding clients food that is not of good quality, LPA observed food supplies to be stocked and of good quality, canned foods were dated, milk was fresh and found to not be expired. Information from outside parties had no concerns about food quality as it was fresh, frozen, and canned.

continued on LIC9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Anthony Loera
LICENSING EVALUATOR SIGNATURE:	DATE: 07/31/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 21-AS-20250605090523

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: SHALAMO HOME	FACILITY NUMBER: 216803917
	VISIT DATE: 07/31/2025

NARRATIVE

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Complaint alleged staff did not provide adequate supervision resulting in client (C1) missing their medication dosage on 06/01/2025 at 2:30PM, Medication records are initialed R indicating medication was refused by C1 on 06/01/2025 at 2:30PM. Staff (S1) confirmed an R initial indicates a client refused medication. Information from outside parties observed no medication issues.

Complaint alleged facility did not have a direct care lead staff on duty at all times, records of staff schedule show there is sufficient number of staff for each shift, AM (7am – 3pm), PM (3pm – 11pm), and NOC (11pm – 7am). Per regulation 85065 Personnel Requirements, (b) The licensee shall employ staff as necessary to ensure provision of care and supervision to meet client needs. Regulation does not state there needs to be a lead staff on duty.

Complaint alleged staff are not properly trained to dispense medication, records of training provided during the investigation show staff have the required training as staff have their Direct Support Professional (DSP) training and required initial training hours upon hire.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.

SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Anthony Loera
LICENSING EVALUATOR SIGNATURE:	DATE: 07/31/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2025

LIC9099 (FAS) - (06/04)

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